Second Nature?

Photo illustration: Jason E. Kaplan and Joan McGuire

Health monitoring, remote therapy and predictive AI have emerged to combat the growing mental health crisis — but too much tech is part of the problem.

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0222 insideIllo healthtech2flatPhoto illustration: Jason E. Kaplan and Joan McGuire

Between 2017 and 2018, one in five Americans reported experiencing symptoms of mental illness, according to Mental Health America, a behavioral health advocacy organization.

In September of 2020, the organization found that number had climbed to 80%.

The problem is worse in Oregon. The nonprofit ranks Oregon the worst state in the country for prevalence of mental illness, and 47th out of 50 for prevalence of mental health issues among children. Oregon is also short of mental health professionals. According to a survey in June 2021 by the Oregon Council for Behavioral Health, 20% of behavioral health providers reported it took six months or longer to fill an open position. Another 18% reported they had continuing job openings due to lack of candidates.

Technology trends — including breathing and meditation apps, remote health coaching, behavioral monitoring and predictive AI — are rising to fill the gap. A technological revolution in the field of mental health and wellness is expanding access to services and improving outcomes. But that technological shift has also brought on new challenges — including screen addiction, isolation and apps employing questionable therapy methods. In order to overcome these challenges, the newest wellness tech innovators are finding ways to connect clients with nature, live professionals and loved ones. And advancements in AI and biometric monitoring are letting robots fill in when a human might not be available.

According to a January 2021 report published by the American Psychological Association, there are between 10,000 and 20,000 apps currently available. Studying the impacts of mental health and wellness apps on the whole is difficult. Not all mental health and wellness apps are created with the same amount of peer-reviewed rigor, but health care providers are already incorporating them into their wellness plans.

In 2018 Kaiser Permanente began providing members with Calm, a mindfulness and guided-meditation app to reduce stress and improve sleep, as well as myStrength, a behavioral therapy app that can mitigate symptoms of anxiety and depression through touch-guided support and activities. These apps are not meant to replace work with a professional, but by reducing stress, a patient can improve overall health outcomes.

Since a significant amount of health care providers’ expenses come from late-stage care, preventive measures have both an ethical and a financial incentive. Peter Nixon, executive director for Mental Health and Wellness at Kaiser Permanente, says these apps produce compelling results when patients use them regularly. One of the biggest challenges to wellness apps’ efficacy, however, is consistent use.

“One issue we have with these kinds of apps is that patients don’t necessarily engage with the tools as often as they need to for them to be effective,” says Nixon. “There tends to be a drop-off rate after a couple of weeks that is rather high.”

0222 healthtech ksanaKsana co-founders Nick Allen (left) and Will Shortt.  Photo: Jason E. Kaplan

To address this challenge, an emerging subset of wellness apps is designed to monitor a subject’s behavior patterns continuously. Ksana Health, a Eugene-based health and wellness monitoring platform, aims to advance the field of mental health and wellness by monitoring the daily lives of participants and providing automatic assessments and recommendations to health care providers. Much like a Fitbit or other wearable device, Ksana tracks a user’s movement and sleep by monitoring their phone. But Ksana takes things further and can gauge a user’s social interaction and mood by analyzing texts and phone calls.

“Language continues to be a key focus for us. We know language is a marker of how people feel day to day. It’s one of the biggest ways people express their existence,” says Ksana co-founder Nick Allen, who is also a psychology professor at the University of Oregon. “Natural language processing is a rapidly developing field of artificial intelligence.”

Ksana sends its collected data to providers to develop health care plans specific to each individual. The app then gives alerts and reminders to help the individual follow through on their plan. With technology like Ksana doing the analysis and heavy lifting, patients would have to spend less time in the office, potentially allowing mental health professionals to service more individuals.

“Our mental health system is out of whack currently. The demand has doubled. The critical foundational piece that we are bringing is accessibility,” says Ksana co-founder Will Shortt, a software-business veteran whose resume includes roles as director of global sales at Symantec and as CEO and co-owner of DECK Monitoring, which monitors energy use.

To improve its product, Ksana Health is partnering with NatureQuant, another Eugene-based tech company, to assist with an emerging practice called eco-therapy, or nature therapy — the practice of spending time in nature to boost mental health outcomes.

Allen says he became interested in nature’s impact on mental health while facilitating a retreat for young people in Australia. When students were in natural areas, Allen saw significant behavioral improvements, some of which he described as “transformative.”

0222 healthtech graphicNatureQuant graphic

Jared Hanley, founder and CEO of NatureQuant, describes his product as a “nature prescription app.” The app uses personalized data-collection tools to inform users when they need to spend time in nature, and for how long. The company’s tech also generates “nature scores” for parks and natural settings near the user — combining factors like noise pollution and the presence of natural formations like lakes and trees to determine the overall effect of the environment on a user’s mental well-being.

“When you’re outdoors and you’re reflecting and connecting with nature, it gives you a sense of wonder. It deepens your connection to the greater universe. When you put down the phone and go outside, all your metrics get better. We’ve seen the trackers. Even your immune system gets better,” says Hanley.

“Humans spend 97% of our time inside, but we spent 99% of our history evolving outside,” Hanley adds. “The concept has been around for thousands of years, but science only began catching up with the philosophy in the last 50.”

A 2020 literature review from the American Psychology Association (APA) found exposure to natural environments “improves working memory, cognitive flexibility and attentional control.” A 2019 study from U.K. medical journal The Lancet found time spent in green spaces had a direct correlation with positive mental health outcomes.

Perhaps ironically, the app is also designed to get users to spend less time on their phones and mobile devices. The same APA literature review found the negative psychological effects of excessive indoor screen time could be mitigated by looking at nature.

Research is mounting about the negative impact of screen time and social media on mental health.

“If more time using technology causes us to be less physically active and spend inadequate time connecting socially to others, then this can contribute to or exacerbate depression and anxiety,” says Kevin C. Garrett, clinical director of the M.S. marriage and family therapy master’s degree program at Oregon Institute of Technology. “Given that quality social relationships are one of the best predictors of physical health, mental health and life satisfaction, anything — including screen time — which significantly disrupts our relationships can be harmful to our health.”

Social media, designed to be attention-grabbing, can cause users to move rapidly from tab to tab and notification to notification, releasing unnatural levels of dopamine in the brain, creating anxiety and addictive behavior patterns.

0222 healthtech hanleyNatureQuant’s Jared Hanley.  Photo: Jason E. Kaplan

“One thing we do is tell the user, ‘Don’t pay attention to this app.’ We want you to get up and enjoy your surroundings,” says Hanley.

One area of concern surrounding wellness and mental health apps like Ksana is data security. The more closely an app monitors a user’s texts and telephone calls for therapeutic purposes, the more likely a cyberattack could reveal highly sensitive information. The Ksana co-founders emphasized that developers go to great lengths to keep users’ data secure.

Hospital systems are also becoming more aware of the threat posed by cyberattacks aimed at prying loose user data. In order to safeguard users’ security, Kaiser Permanente currently does not track which individual members register for its wellness apps, or how its members access the content in the app on an individual level. But the health care provider is using its patients’ data to develop predictive AI tools.

Kaiser is using machine-learning models to develop and test a more sophisticated and accurate way to predict risk of suicide by combining mental health questionnaire responses with information from electronic health records, including prior suicide attempts and diagnoses of mental health and substance use. Nixon said the health care provider is in the process of testing the suicide-prevention tool in several of its regions.

The field of robotics is also rising to meet the current mental health crisis. Dr. Naomi Fitter, assistant professor in the School of Mechanical, Industrial, and Manufacturing Engineering at Oregon State University, currently develops support robots and other AI therapeutic machines that can respond to a user’s biological signals. Called haptic technology, robots, as well as wearable gloves and vests, can monitor a user’s biological signals through touch, assess them and respond.

“In my work on inflatable soft robots for anxiety management, we need to understand when the user is experiencing moments of anxiety in order to be able to intervene effectively,” says Fitter, who adds that biofeedback tools can be applicable to a wide variety of therapeutic techniques.

“This understanding can be used by our robotic system, but it can also be used independently to supply a person with information about when they typically experience anxiety. This type of information can help with self-reflection and strategizing, even before we bring a robot into the picture.”

Among the devices being developed at OSU are desk-sized robot buddies who nudge users like a pet, a mobile robot that encourages users with prompts and a vest that hugs users experiencing stress. Fitter says a robot’s comforting physical presence can provide something apps cannot.

Robotic companions are of special interest to senior populations, as they can provide both emotional as well as physical support.

“Robot embodiment [can] make robots more influential, more agentic, or more engaging to interact with compared to non-embodied solutions like a video of a robot or a phone or computer application,” says Fitter.

The field of wellness coaching has also seen benefits from the digital technology revolution. Now employed by doctors and health care providers including Providence, Moda Health and Kaiser, wellness coaching involves a patient talking to a trained behavior change specialist to set incremental goals to achieve their desired health outcomes.

Users’ increasing comfortability with telehealth has made the practice more popular, according to Leigh-Ann Webster, executive director for the National Board for Health & Wellness Coaching. Since the onset of COVID-19, the number of certified health and wellness coaches has more than tripled, from 2,000 in 2019 to over 6,500 now, according to Webster.

However, popular tech-based trends in wellness coaching, including coaching by text message and the development of AI health coaches, have not been studied enough for their efficacy to be proven.

“Technology is a bit ahead of where the field really is,” says Webster. “Technology has really opened up the practice, but there hasn’t been as much research into the effectiveness of some of these new practices.”

And some wellness apps are controversial. For one thing, they’re not regulated: The FDA considers many health apps “general wellness products” and does not regulate them. One popular app, Noom, has also been criticized for encouraging dangerously low caloric intake, though ads for the app explicitly say it’s not a diet. (Noom did not respond to a request for comment in time for Oregon Business’s deadline, though a spokesperson did tell us the app does not use artificial intelligence.)

“There are a ton of investment firms putting money into AI in the health and wellness space,” says Webster. “There’s probably a place for both. I think there’s still some work to be done in terms of standards and impact.”

0222 healthtech screenshotsScreenshots of Ksana and NatureQuant’s smart phone apps

For Ksana and NatureQuant, the next step in their collaboration is bringing in new research. The two companies have joined forces with partners from the European Union, including Cambridge University in the U.K., University Children’s Hospital Bern in Switzerland and Radboud University in the Netherlands to conduct research studies using the Effortless Assessment Research System (EARS) tool, which is built using the same continuous objective measurement platform. Ksana Health was also selected by Danish pharmaceutical company Novo Nordisk to be part of its Prevention Accelerator program, where it will collaborate with other companies with potential to “make a global impact” on health care outcomes.

According to Hanley, Nature-based mental health research is “further along” in Europe than it is in the United States.

Part of popularizing the research is helping to make it more affordable. The more insurance companies see the improved health outcomes of wellness technology, the more they will be willing to cover the costs. Allen is confident that once the benefits of Ksana and NatureQuant are seen by insurance companies, they will take pains to ensure their clients receive it.

As human reliance on technology increases, there will likely be more mental health and stress-related problems. Debate continues to rage in the psychiatric community about how much screen time and technological saturation can be linked to cases of depression, anxiety and ADHD. But humans’ reliance on technology and rapidly evolving trends in virtual reality and artificial intelligence mean the future will likely involve more digital tools, not less.

Mental health and wellness professionals will have to adapt.

“Digital technology is not going away,” says Allen. “Any idea that we’re going to get rid of our smartphones is fanciful, in my opinion, so we need to find a way to use them to improve mental health and improve overall health.”

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